PARTOGRAPH

Dr Sheela V.Mane Chairperson-Safe Motherhood Committee,FOGS

Dr Sheela V.Mane

Dr Sheela V.Mane

Maternal Mortalit!

Half a million women lose their lives every year because of pregnancy Obstructed labour and ruptured uterus contribute upto 70 of maternal mortality !arly detection of abnormal progress " prevention of prolonged labour can significantly reduce MM
Dr Sheela V.Mane 3

O"#e$ti%e of this &OC drill

#o teach the use of $artograph in the management of labour

( Not to teach the principles and physiology of labour}

Dr Sheela V.Mane

'! the end of the pro(ram the parti$ipant sho)ld "e a"le to*

%now when to start a $artograph &nderstand and complete all parts of the $artograph Describe all abnormalities in labour %now how to recogni'e prolonged labour on the $artograph %now when to transfer a woman in labour Have some (nowledge of possible management Dr Sheela V.Mane options
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Parto(raph

Graphi$ re$ordin( of the pro(ress of la"o)r Re$ordin( of salient $onditions of the mother and fet)s

+ses

To dete$t la"o)r that is not pro(ressin( normall! To indi$ate ,hen a)(mentation of la"o)r is appropriate To re$o(ni-e CPD lon( "efore o"str)$tion o$$)rs
Dr Sheela V.Mane 6

Parto(raph

)ncreases the *uality of all observations on the mother and fetus in labour Serves as an +!arly warning system, -ssists in early decision on transfer. augmentation. termination of labour
Dr Sheela V.Mane 7

Dr Sheela V.Mane

Dr Sheela V.Mane

.ho sho)ld not ha%e a Parto(raph

/omen with problems which are identified before labour starts or during labour which need special attention

Dr Sheela V.Mane

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O"ser%ations $harted on the Parto(raph

The Pro(ress of la"o)r 0ervical dilatation Descent of fetal head &terine contractions 1 duration. fre*uency Fetal $ondition 2etal heart rate Membranes and li*uor Moulding of the fetal s(ull Maternal $ondition $ulse3 4$ 3 #emp &rine 1 volume. acetone. protein Drugs " )V 2luids O5ytocin regime Dr Sheela V.Mane

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Startin( a Parto(raph
- partograph should be started only when a woman is in active phase of labour

0ontractions must be 6 or more in 60mins. each lasting for 70secs or more

0ervical dilatation must be 8cms or more

Dr Sheela V.Mane

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)n the centre of $artograph is a 9raph. -long the left side are numbers 0 :60 against s*uares. !ach s*uare represents 6cm dilatation.

-long the bottom of the graph are numbers 0:78. !ach s*uare represents 6hour

#he dilatation of 05 is plotted with an ;<=. Vaginal e5aminations are done at admission and once in 8 hours
Dr Sheela V.Mane 13

)n the centre of $artograph is a 9raph. -long the left side are numbers 0 :60 against s*uares. !ach s*uare represents 6cm dilatation.
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-long the bottom of the graph are numbers 0:78.

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!ach s*uare represents 6hour

#he dilatation of 05 is plotted with an ;<=. Vaginal e5aminations are done at admission and once in 8 hours // /0
/ 0 /1 1 /2 2 /3 3 /4 4 /5 5 /6
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Dr Sheela V.Mane

Des$ent of fetal head

t is meas)red in terms of fifths a"o%e the pel%i$ "rim

Dr Sheela V.Mane

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The ,idth of the 3 fin(ers is a ()ide to the e8pression in fifths of the head a"o%e the "rim. A head that is mo"ile a"o%e the "rim ,ill a$$ommodate the f)ll ,idth of 3 fin(ers

Dr Sheela V.Mane

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-s the head descends. the portion of the head remaining above the brim will be represented by fewer fingers

Dr Sheela V.Mane

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t is (enerall! a$$epted that the head is en(a(ed ,hen the portion of the head a"o%e the "rim is represented "! 0 fin(ers are less

Dr Sheela V.Mane

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Plottin( the Des$ent of the Head

On the left hand side of the (raph is the ,ord 9des$ent: ,ith lines (oin( from 3 ; < Des$ent is plotted ,ith an 9O: on the Parto(raph

6 A

7 60

>

8 ? @ 66 67 6>
Dr Sheela V.Mane

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+terine Contra$tions
O"ser%ations are e%er! half ho)r in a$ti%e phase

2re*uency : Bumber of contractions in a 60 minutes period

Duration 1 Measured in seconds from the time the contraction sets in to the time the contraction passes off
Dr Sheela V.Mane 20

Re$ordin( +terine Contra$tions

On the Parto(raph "elo, the time line, there are 3 "lan= s>)ares (oin( a$ross the len(th of the (raph. &a$h s>)are represents / $ontra$tion

Dr Sheela V.Mane

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Plottin( Contra$tions on the Parto(raph

Dr Sheela V.Mane

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Fetal Heart Rate

?isten $atient in left lateral position Cust after the contraction has passed its strongest phase 2or 6 full minute. if abnormal every 6?mins )f abnormal over > observations. ta(e action Re$ord -t the top of the $artograph !very half hour

Dr Sheela V.Mane

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Mem"ranes @ ?i>)or
State of ?i>)or Re$ord

Mem"ranes inta$t Clear Me$oni)m A"sent 'lood Stained C M A '

Dr Sheela V.Mane

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Fetal $ondition

State of Mo)ldin( 4ones are separated " sutures felt

Re$ord O

4ones are Dust touching each other

Dr Sheela V.Mane 4ones are overlapping

6E 7E
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Maternal Condition
Re$orded at the foot of the Parto(raph O8!to$in* Dr)(s* P)lse* e%er! half ho)r 'P* e%er! 2 hrs or more fre>)entl!

Temp* e%er! 2 hrs or more fre>)entl! +rine* Protein A$etone Vol)me

Dr Sheela V.Mane 26

Points to Remem"er

/hen the woman comes in the active phase of labour. recording of cervical dilatation starts on the alert line /hen progress of labour is normal. plotting of cervical dilatation remains on the alert line or to the left of it

Dr Sheela V.Mane

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A"normal Pro(ress of ?a"o)r

Dr Sheela V.Mane

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Prolon(ed A$ti%e Phase

)n the active phase. plotting of cervical dilatation will remain on the left of or on the alert line )f it moves to the right of the alert line. labour may be prolonged #ransfer if facility for emergencies is not available #ransfer allows ade*uate time for assessment for intervention when she reaches the action line
Dr Sheela V.Mane 29

Prolon(ed a$ti%e phase of la"o)r

Dr Sheela V.Mane

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At the A$tion ?ine

)t is 8 hours to the right of -lert line -ssess the cause of slow progress and ta(e action -ction should be ta(en in a place with facility for dealing with obstetric emergencies is available

Dr Sheela V.Mane

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Remem"er

.ARA AG Transfer from hospital Feaching the action line means POSS '?& DAAG&R on further management
(usually by obstetrician or medical officer)
Dr Sheela V.Mane 32

Mana(ement of

?a"o)r .HO Proto$ol

Dr Sheela V.Mane 33

Aormal ?atent and A$ti%e Phases

Latent phase is less than 8 hrs and active phase remains to the left of or on the alert line

Do not a)(ment ,ith o8!to$in or inter%ene )nless $ompli$ations de%elop

ARM ma! "e done at an! time in the a$ti%e phase

Dr Sheela V.Mane

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'et,een Alert and A$tion lines

In a Health Centre:

#ransfer to hospital with facilities for 0esarean section. unless 0ervi5 is almost fully dilated -FM may be performed if membranes are still intact and observe labour for a short period before transfer

In Hospital:

$erform -FM if membranes are intact and continue routine observations

Dr Sheela V.Mane 35

At or 'e!ond A$ti%e Phase A$tion ?ine

F)ll medi$al assessment Consider V inf)sionB"ladder $atheteri-ationBanal(esia Options* Deli%er! if fetal distress or o"str)$ted la"o)r O8!to$in a)(mentation if no $ontraindi$ation S)pporti%e therap! Conl! if satisfa$tor! pro(ress is no, esta"lished and dilatation $o)ld "e anti$ipated at /$mBhr or fasterD
Dr Sheela V.Mane 36

Dilatation that rea$hes the A$tion ?ine

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nade>)ate )terine $ontra$tions $orre$ted ,ith o8!to$in

Dr Sheela V.Mane

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COATR '+TORS

Dr Dr

Sheela V.Mane S)sheela Rani

Dr Sheela V.Mane

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Dr Sheela V.Mane

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